Musings

Below you will find adaptations from a few random articles I have written over the years that I previously published under what I called Health Tips. While many articles originally written are dated or no longer relevant, I have found that I keep coming back to these four articles.

​Wellness Program for Diabetes and Heart Disease Prevention: How to be Healthy Without Drugs

As many of you know, I have been wandering further and further into the realm of prevention over my professional career. It started in earnest when we started offering the Cornerstone Wellness weight management program, and I realized how much diet can affect a person's health. About 10 years ago, we began offering specialized, sophisticated blood testing called advanced lipid testing, and a few years later we started offering CIMT (Carotid Intima Media Thickness) testing. In the meantime, I have read countless numbers of books & articles, have watched many videos of lectures, and have gone to many conferences and symposia on the subject.

I've come to the conclusion that most problems of obesity, diabetes and heart disease are all intimately related and can be prevented given the right lifestyle. The earlier in life this started however, the more success lifestyle changes are in preventing disease. Once someone is an adult and there is already some damage, less can be done.

Many people believe that early man (prior to 10,000 years ago when we became agrarian) ate mostly meat. Apparently, we know this by looking at fossilized poop (among other things) and by accounts given by explorers that came in contact with hunter-gatherer tribes over the past several hundred years. These populations were found to be extremely healthy. Heart disease, diabetes, obesity, cancer, arthritis, autoimmune disorders, tooth decay, and even acne were almost unheard of. Once these populations began eating a more modern diet, those diseases became a problem for them also.

I've often been reminded that early man had a ridiculously low life expectancy, so why would we aspire to that? Early man had a high infant mortality rate, and only primitive medical care when faced with trauma or infection. If those causes of death are taken out, early/primitive man had as good or better life expectancy than we do now. And, they were healthier. BTW - the evidence is against early/primitive man being super active as the reason for their health. Apparently, we spent as little time as possible hunting, gathering, and making shelter, maybe 3 only hours a day!

So that leaves our diet as a major difference. In general, early/primitive man ate much more animal fat than we do now. They ate very few if any grains, since grains need to be processed to be edible. The only sweetener available would be honey, and since that is very tricky to obtain, he wouldn't have had that very often. They did eat fruit and the fruity vegetables (like tomatoes and peppers), but had limited access as they could not go to the supermarket and buy them any time of the year. In addition, most of the fruits and vegetables we eat today have been bred to be much sweeter and bigger than what was originally available in nature.

So what did that leave us with? Lots of meat, with some bitter vegetables and tart fruit in season, nuts, eggs, and mushrooms (also in season only). And apparently we were very healthy, especially if we lived past infancy and avoided tigers.

The next question I'm asked is, doesn't that screw up our cholesterol? The short answer is no. That's where the sophisticated lipid testing comes in; we can see the positive changes diet does, and in many cases have avoided medication. Oh, and as a side effect most people lose weight and feel much more energetic. That's my ultimate goal, to make people healthier and live longer without medication.

​What Makes Us Fat

To combat obesity, we need to understand fat. This will get a little technical, but bear with me, because understanding the physiology behind fat storage is extremely enlightening when trying to make lifestyle changes. What I'm about to explain actually comes out of basic medical textbooks, and in that sense is not controversial.

Basically, foods are either composed of fats, proteins, or carbohydrates (CHO) or a mixture of the three. When we eat food, the proteins are absorbed as proteins, fats as fatty acids (FA) and carbohydrates as various forms of glucose (sugar). All three can be used for fuel. Right now we are only interested in FA and CHO.

When we eat, CHO will be absorbed and cause a rise in glucose (blood sugar). Insulin is then produced by the pancreas to allow the glucose to be taken up by the cells as fuel. Glycerol is then produced as a byproduct. FA can also be used as fuel. BTW - the liver can and will also produce glucose and fatty acids when necessary. In the fat cells, fat is stored as triglycerides (TG), which are comprised of one glycerol molecule + three FA molecules. Glycerol is produced when glucose is used as fuel. TG's are too big to go through the cell walls so must be broken down into its individual pieces to go through the wall. The only way glycerol can get into the fat cell is with the help of insulin, and the only way it can get out is when the insulin level is very low.

So the fat in the fat cells are actually TG molecules that are assembled in the fat cell from glycerol and fatty acids that get stuck there because the TG molecule is too big to get back out. Actually, the TG molecule is constantly breaking up and reforming, but as long as there is a glycerol molecule inside the cell, it will suck in enough FA molecules to make sure it can be a TG. Remember, the only way that glycerol can get out is when the insulin level in the blood stream is very low.

So how do we decrease the storage of fat? We need to prevent TG from forming in the fat cells. Since the liver will produce fatty acids to pair with the glycerol, we need to prevent glycerol from getting into the fat cells. To do that, we need to lower the insulin level in the blood stream. What causes insulin secretion? The ingestion of carbohydrates. So how do we prevent from getting fat? Eat less carbs. That, by the way, is why the Atkins diet worked. People can eat as many calories as they want as long as they eat no carbs and not only will they not get fat, but they will lose fat like crazy because their insulin levels are low and the glycerol and FA's come streaming out of the fat cells.

So you can see why right now all the major players in the weight loss industry are advocating low carb diets. This is only the tip of the iceberg though, and there are more reasons out there as to why it is so difficult to lose weight. If you have questions, I'd love to talk about your situation in person with you; feel free to come in for an appointment to discuss this further.

​Why Doctors Often Run Late

Even though I wrote this several years ago, the information is still relevant and correct. Even though we schedule a little differently now, many of the issues are the same, so it still applies. I hope it will make you feel a little less irritated while waiting for me (or any other healthcare provider) to see you.

Some time ago, I walked into an exam room and found it empty. I asked my staff what happened to the patient. They said she left quite angry, saying she had waited too long to see me. I looked at my appointment screen, hers had been 7 minutes earlier; I had thought I was doing great. Apparently, she had arrived more than 30 minutes prior to her appointment time, so she had actually been waiting 40 minutes. She knew she was early but did not take that into account.

As health care providers, we try our best to stay on time, but have many factors working against us. I thought you might find it interesting to see how things run in our office, so one morning I noted the times when patients arrived, were seen, and when I left the room, compared to what time their appointment was scheduled. I hope you find it interesting, and maybe someone can figure out a better way of doing this!

First, some information: At the time this was a typical schedule for me; I booked every 15 minutes, with 30 minutes for physicals. In an attempt to improve things, I now book every 30 minutes, and double book emergencies or quicker visits. This is unusual, most primary care providers book every 15 minutes and double book those.

Moving a patient through the office quickly takes a lot of cooperation between the reception and back office (nursing) staff. Some patients need time to fill out paperwork, or just chat. It is not always easy to move things along, even before they get to the exam room. If I am in the back waiting for someone to complete paperwork, everyone after that person will most likely have to wait.

On to the schedule, with patients listed in order of appointment time.

1. The 8 am appointment was scheduled to last for 30 minutes, she arrived at 8, was seen at 8:05, and finished by 8:35. Not bad, except the next patient didn't arrive for another 14 minutes (#3), putting me 19 minutes behind. My schedule was already screwed up.

2. The 8:30 called to say he was stuck in traffic and would be late. He arrived at 8:57, at the same time as 2 others. I saw the others first, and he was seen after #5 at 9:34, out at 9:54.

3. The 8:45 had an urgent problem and was worked in, couldn't be seen later due to another appointment. Arrived 8:49, seen at 8:50, out by 8:58.

4. The 8:45 arrived at 8:57 (no explanation) seen at 8:58, out by 9:12.

5. The 9 am appointment was scheduled for 30 minutes, arrived at 8:57, seen at 9:13, and out at 9:33. We would have been doing great, except I still hadn't seen see patient #2.

6. 9:30 appointment arrived at 9:32, seen at 10:08, out at 10:34.

7. The 9:45 also arrived at 9:32, seen at 9:58, out at 10:41. I knew a test would need to be run for this one, so started here, took care of #6, then came back to finish.

Now it was 10:41, and I was about to go in to see my 10:00 appointment.

8. The 10:00 patient arrived at 10:00, seen at 10:41, out at 10:54.

9. 10:15 appointment was scheduled for 30 minutes, arrived at 10:24, seen at 10:54, out at 11:13.

10. The 10:45 arrived at 10:42 (would have been perfect, if I had not been running behind), was seen at 11:14, out at 11:32.

11. The 11:00 appointment arrived at 11:13, was seen at 11:41, out at 11:57. They arrived late for their appointment, so were put behind #12. This one also needed a test, so I started here, went to #14, and then returned to finish.

12. The 11:15 arrived at 11:04, was seen at 11:33, out at 11:40.

13. The 11:30 arrived at 11:45, was seen at 12:15 out by 12:30. Was seen after #14.

14. The 11:45 also arrived 11:45, was seen at 11:45, out by 12:10. Was seen after #11. Then I needed to change the computer's battery, got a quick snack , and went to see #13.

15. An 11:45 appointment was added onto the schedule at the end (work in) and arrived at noon, was seen at 12:32, done by 12:55.

At this point I was very tired and hungry, and glad to be done with the morning! I finished the morning about an hour after expected. Only 7 of 15 patients arrived at or before their appointment times. Of those that arrived on time 2 were seen immediately, 2 within 15 minutes of their appointment time, 2 within 30 minutes of their appointment time, and poor #8 was seen 41 minutes late. Frankly, those who arrived late have no reason to complain about a wait, many places would charge them a fee and tell them to reschedule (and after looking at this - for good reason!).

I realize not everyone will read through this schedule (it makes my head spin just looking at it!). I did want to make a point though. We all hate to wait, and most doctors hate running behind, but our schedules are often beyond our control. Even carefully planned schedules go out of whack. We are dealing with humans, and they and their problems are unpredictable.

I hope this gives you some appreciation for why you may be waiting next time you come in. My goal is to have no one wait (I love finishing on time!), but unfortunately, that is often impossible.

​Piercing Ears and Other Body Parts or We Pierce Ears (but only ears, and only the lobes)

You've promised your daughter that she can have her ears pierced for her 10th birthday. Unfortunately, she turns 10 in 2 weeks. You know the store in the mall that sells earrings also pierce, but you wonder how safe they really are. Are your fears grounded? Maybe.

Or maybe your 16 year old wants a naval piercing. You're not very excited about this, but after much negotiating, you've given in. Where can you go that's safe?

Piercing has been practiced for thousands of years. When done using sterile techniques, complications are rare. The most common complication will be infection. Sometimes the infection is minor, but more serious infections include abscess formation (pus pockets), cellulitis (infection of the surrounding skin), and even spreading through the blood stream (sepsis). Treatment of serious infections may require antibiotics (oral or through an IV) and surgery, which can result in disfigurement.

It is important that clean instruments are used when piercing. Piercing guns are not recommended. They cannot be properly sterilized and there have been cases of hepatitis transmission through piercing guns. Other options include single use instruments, and piercing needles that can be autoclaved. Which is chosen depends on the site to be pierced. A piercing needle can be used in almost any location. All equipment that is not disposable should be autoclaved (sterilized) prior to each use. A reputable piercer should be happy to discuss their sterilization technique with you.

I have single use (Coren) ear piercers in the office. They come preloaded with the earring, sealed in a plastic wrapper. The earrings are either plated with 24K gold or are stainless steel. There should be little or no risk of infection or allergic reactions using these, which is why I chose to use them. They work great on ear lobes, but unfortunately are not useful in other areas.

After piercing, the area should be cleaned twice daily with soap and water. Soaking the area in a salt water solution may also be useful. Whether or not the jewelry should be spun (or rotated) is a matter of debate. Alcohol and peroxide tends to dry the skin out, and no are longer recommended (although it depends on the site pierced). Hands should always be washed prior to touching the newly-pierced area. Healing time depends on the area pierced. Ear lobes usually take 6-8 weeks, navel 6-12 months. Most other areas are somewhere in between.

The risk of infection is greater in areas where there is less blood supply. There was an article published in The Journal of the American Medical Association reporting severe infections that were traced back to a jewelry kiosk in Oregon. They were using a contaminated bottle which was filled with disinfectant and sprayed on the clients and instruments. Only those who had their ear cartilage pierced (almost no blood supply) had severe infections, compared to those whose lobes were pierced.

Please be very careful when having a body part pierced. Make sure you confirm and are comfortable with the cleanliness of the piercer and tools. Be careful to keep the area clean afterwards; at least until it is fully healed. Remember, this is an open wound. Finally, if you suspect the area has become infected, please see your doctor ASAP.